Provider Demographics
NPI:1356311930
Name:WILSON, ROBERT (DO)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:
Last Name:WILSON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5239 W ROSE GARDEN LN
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85308-9358
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7219 N LITCHFIELD RD
Practice Address - Street 2:LUKE AIR FORCE BASE - FAMILY MEDICINE DEPT
Practice Address - City:LUKE AFB
Practice Address - State:AZ
Practice Address - Zip Code:85309
Practice Address - Country:US
Practice Address - Phone:623-856-9007
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-25
Last Update Date:2010-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ4666207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine